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Clinical Edits

The Texas Managed Medicaid STAR/CHIP formulary, including the Preferred Drug List and any clinical edits, is defined by the Texas Vendor Drug Program.

Texas Vendor Drug Program Clinical Edit Website: https://www.txvendordrug.com/formulary/prior-authorization/mco-clinical-pa

Please click on the link(s) below to view the Texas Medicaid STAR and CHIP implemented clinical edits.

Click here for Prior Authorization information.

Type Name File Size
PDF File Accolate
Eff. Date: 08/28/2019
 ACCOLATE, ZAFIRLUKAST 469 KB
PDF File ADD_ADHD
Eff. Date: 05/20/2020
 ADDERALL, AMPHETAMINE, AMPHETAMINE/DEXTROAMPHET SALTS, DESOXYN, DEXMETHYLPHENIDATE, EVEKEO, FOCALIN, METHAMPHETAMINE, METHYLIN, METHYLPHENIDATE, PROCENTRA, RITALIN, ZENZEDI, ADZENYS, ADZENYS-ODT, AMPHETAMINE/DEXTROAMPHET SALTS ER, ADHASIA XR, APTENSIO XR, CONCERTA ER, COTEMPLA, DAYTRANA, DEXEDRINE, DEXMETHYLPHENIDATE, DYANAVEL, FOCALIN XR, METHYLPHENIDATE ER, METHYLPHENIDATE CD, MYDAYIS, QUILLICHEW, QUILLIVANT, RITALIN, VYVANSE, GUANFACINE, INTUNIV, STRATTERA, CLONIDINE 933 KB
PDF File Agents for Gaucher’s Disease - HHSC
Eff. Date: 7/15/2019
 CERDELGA, CEREZYME, ELELYSO, MIGLUSTAT, VPRIV, ZAVESCA 410 KB
PDF File Aliskiren - HHSC
Eff. Date: 03/21/2019
 TEKAMLO, TEKTURNA, AMTURNIDE, TEKTURNA HCT 1 MB
PDF File Allergen Extracts - HHSC
Eff. Date: 12/10/2019
 ORALAIR 350 KB
PDF File Antiemetics - HHSC
Eff. Date: 3/21/2019
 AKYNZEO, ANZEMET, APREPITANT, EMEND, GRANISETRON HCL, SANCUSO 291 KB
PDF File Antipsychotics
Eff. Date: 07/30/2020
 ABILIFY, ABILIFY DISCMELT, ABILIFY MAINTENA, ABILIFY MYCITE, AMITRIPTYLINE/PERPHENAZINE, ARIPIPRAZOLE, ARISTADA ER, CAPLYTA, CHLORPROMAZINE, CLOZAPINE, CLOZAPINE ODT, CLOZARIL, FANAPT, FAZACLO, FLUPHENAZINE, GEODON, HALOPERIDOL, INVEGA ER, INVEGA SUSTENNA, INVEGA TRINZA, LATUDA, LOXAPINE, MOLINDONE HCL, OLANZAPINE, OLANZAPINE ODT, OLANZAPINE/FLUOXETINE, ORAP, PALIPERIDONE ER, PERPHENAZINE, PERSERIS ER, PIMOZIDE, QUETIAPINE , REXULTI, RISPERDAL , RISPERDAL CONSTA, RISPERDAL M-TAB, RISPERIDONE, SAPHRIS, SECUADO, SEROQUEL, SYMBYAX, THIORIDAZINE, THIOTHIXENE, TRIFLUOPERAZINE, VERSACLOZ, VRAYLAR, ZIPRASIDONE, ZYPREXA, ZYPREXA RELPREVV, ZYPREXA ZYDIS 567 KB
PDF File Anxiolytics and Sedatives Hypnotics (ASHs) - HHSC
Eff. Date: 2/18/2020
 ALPRAZOLAM, XANAX, CHLORDIAZEPOXIDE, MEPROBAMATE, OXAZEPAM, DIAZEPAM, CLONAZEPAM, KLONOPIN, CLORAZEPATE, TRANXENE T, LORAZEPAM, TEMAZEPAM, TRIAZOLAM, ZOLPIDEM, ESTAZOLAM, RESTORIL, TEMAZEPAM, ESZOPICLONE, LUNESTA, SONATA, ZALEPLON, INTERMEZZO, ZOLPIDEM, AMBIEN, EDLUAR, BELSOMRA, BUTISOL SODIUM, FLURAZEPAM, HETLIOZ, ROZEREM 740 KB
PDF File Arikayce HHSC
Eff. Date: 4/26/2019
 ARIKAYCE 218 KB
PDF File Buprenorphine Agents – HHSC
Eff. Date: 03/22/2019
 BUNAVAIL, BUPRENORPHINE, BUPRENORPHINE-NALOXON, SUBOXONE, ZUBSOLV 809 KB
PDF File Carisoprodol - HHSC
Eff. Date: 05/23/2019
 CARISOPRODOL-ASPIRIN, CARISOPRODOL COMPOUND, CARISOPRODOL CPD-CODEINE, CARISOPRODOL, SOMA 260 KB
PDF File CGRP Antagonists HHSC
Eff. Date 08/29/2019
 AIMOVIG, AJOVY, EMGALITY 314 KB
PDF File CNS Stimulants - HHSC
Eff. Date: 10/29/2019
 ARMODAFINIL, MODAFINIL, NUVIGIL, PROVIGIL, SUNOSI 406 KB
PDF File Contraceptives - CHIP ONLY
Eff. Date: 10/22/2012
 22 KB
PDF File Contraceptives - Dell Children’s Health Plan Only
Eff. Date: 12/09/2016
 18 KB
PDF File Cough/Cold Medications - HHSC
Eff. Date: 03/10/2020
 ALA-HIST, ALLFEN DM TAB, AP-HIST DM LIQ, APRODINE TAB, BENZONATATE, BROMFED DM CGH SYR, BROMPHENIR-PSEUDO-DM SYR, BROTAPP, CHEST CONG RELIEF, CHLD DELSYM, CHLD COLD & CGH DM ELIXI, CHLD MUCINEX, CHLD DAYCLEAR ALL CGH, CHLO TUSS LIQ, CGH DM, CGH SYR, DALLERGY, DECONEX DMX TAB, DECONEX IR TAB, DELSYM, DEXTROMETHORPHAN ER, DIMAPHEN, ED A-HIST, ED BRON GP LIQ, ED CHLORPED D PEDIATRIC DROPS, ENDACOF-DM LIQ, EX ACTION CGH SYR, GUAIFEN, GUAIFEN ER, GUAIFEN/PSE, HISTEX, IOPHEN, KIDKARE CGH & COLD LIQ, KID'S MUCINEX MINI-MELTS PACK, LODRANE D CAPSULE, LOHIST, LORTUSS, MAXIPHEN, M-END DMX LIQ, M-HIST DM LIQ, MUCINEX, MUCUS RELIEF, NASAL DECON SPRAY, NASOPEN PE LIQ, NINJACOF LIQ, NOHIST, NOSE DROPS, ORGAN-I, PEDIATRIC CGH-COLD LIQ, PHENYLEPHRINE-PYRILAMINE, POLY HIST, POLY-VENT, POLYTUSSIN, PROMETHAZINE, Q-TUSS, RESCON, RESPAIRE-30, ROBAFEN, RU-HIST D, RYMED, SILTUSS, SM NASAL SPRAY, SM TUSS DM, STAHIST AD, SUDOGEST SINUS & ALLERGY TAB, TUSS, VANACOF, VANATAB 438 KB
PDF File COX-2 Inhibitors
Eff. Date: 4/24/2020
 CELEBREX, CELECOXIB, MELOXICAM, MOBIC 1020 KB
PDF File Cystic Fibrosis Agents - HHSC
Eff. Date: 01/30/2020
 KALYDECO, ORKAMBI, SYMDEKO, TRIKAFTA 667 KB
PDF File Cytokine and CAM Antagonists
Eff. Date: 09/07/2020
 ACTEMRA, CIMZIA, COSENTYX, ENBREL, HUMIRA, ILARIS, ILUMYA, KEVZARA, KINERET, OLUMIANT, ORENCIA, OTEZLA, RINVOQ, SILIQ, SIMPONI, SKYRIZI, STELARA, TALTZ, TREMFYA, XELJANZ 3 MB
PDF File Desmopressin
Eff. Date: 5/10/2019
 DDAVP, DESMOPRESSIN ACETATE 561 KB
PDF File Dextromethorphan Overutilization - HHSC
Eff. Date: 12/30/2019
 ALA-HIST DM LIQ, AP-HIST DM LIQ, ALLFEN DM TAB, BROMFED DM CGH, BROMPHENIR-PSEUDO-DM SYR, BROTAPP DM LIQ, CHILD DELSYM, CHILD C&C DM ELIX, CHILD MUCINEX, DECONEX DMX TAB, DELSYM 30MG/5ML SUSP, DELSYM CGH+CHEST CNGST DM LQ, DEXTROMETHORPHAN ER 30MG/5ML, DIMAPHEN DM ELIX, ED-A-HIST DM LIQ, ED-A-HIST DM TAB, ENDACOF-DM LIQ, EXT ACTION CGH SYR, GUIAFEN-DM ER 1,200-60MG TAB, HISTEX-DM SYR, IOPHEN DM-NR LIQ, KIDKARE C&C LIQ, LOHIST-DM SYR, LORTUSS DM LIQ, M-END DMX LIQ, M-HIST DM, MAXIPHEN DM TAB, MUCINEX CGH MINI-MELT PACK, MUCINEX DM ER 600-30MG TAB, MUCINEX DM ER 1,200-60MG TAB, MUCINEX FAST-MAX CONG-CGH, MUCINEX FAST-MAX DM MAX LIQ, NOHIST-DM LIQ, PED C&C LIQ, POLY-HIST DM LIQ, POLY-VENT DM TAB, POLYTUSSUN DM, PROMETH-DM SYR, Q-TUSS DM SYR, RESCON-DM LIQ, ROBAFEN CF LIQ, ROBAFEN-DM, ROBAFEN CGH 15MG LIQGEL, ROBAFEN DM CGH-CHEST CONG SYR, RYNEX DM LIQ, SILTUSS DM CGH SYR, SILTUSS DM DAS LIQ, SM TUSS DM, TUSS DM, VANACOF DM LIQ, VANATAB DM CAP, VIRDEC DM DRP 220 KB
PDF File Diacomit - HHSC
08/20/2020
 DIACOMIT 585 KB
PDF File Diclofenac - HHSC
Eff. Date: 3/27/2019
 DICLOFENAC GEL 3%, DICLOFENAC SOL 1.5%, PENNSAID SOL 2% 300 KB
PDF File Doxylamine/Pyridoxine - HHSC
Eff. Date: 10/29/2019
 BONJESTA ER, DICLEGIS DR 254 KB
PDF File DPP4 Inhibitors - HHSC
Eff. Date: 3/27/2019
 ALOGLIPTIN, ALOGLIPTIN-METFORMIN, ALOGLIPTIN-PIOGLIT, GLYXAMBI, JANUMET, JANUMET XR, JANUVIA , JENTADUETO, JENTADUETO XR , KAZANO, KOMBIGLYZE XR , NESINA, ONGLYZA , OSENI , QTERN , STEGLUJAN, TRADJENTA 314 KB
PDF File Drug Regimen Optimization - HHSC
Eff. Date: 11/22/2019
 ALTACE, DIOVAN, RAMIPRIL 283 KB
PDF File Dupixent - HHSC
Eff. Date: 7/17/2020
 DUPIXENT 379 KB
PDF File Emflaza - HHSC
Eff. Date: 7/03/2019
 EMFLAZA 306 KB
PDF File Enzymes - HHSC
Eff. Date: 09/11/2019
 ALDURAZYME, ADAGEN, CEPROTIN, ELAPRASE, FABRAZYME, LUMIZYME, NAGLAZYME, NITYR, ORFADIN, RECOVI, VIMIZIM 366 KB
PDF File Epidiolex HHSC
Eff. Date: 08/20/2020
 EPIDIOLEX 597 KB
PDF File Erythropoiesis-Stimulating Agents - HHSC
Eff. Date: 3/28/2019
 ARANESP, EPOGEN, PROCRIT 597 KB
PDF File Fentanyl Agents - HHSC
Eff. Date: 3/28/2019
 ABSTRAL, ACTIQ, DURAGESIC, FENTANYL, FENTORA, LAZANDA, SUBSYS 2 MB
PDF File Flexeril/Amrix (Cyclobenzaprine)
Eff. Date: 5/10/2019
 AMRIX, CYCLOBENZAPRINE, FEXMID 475 KB
PDF File GI Motility Agents - HHSC
Eff. Date: 7/30/2019
 AMITIZA, LINZESS, ALOSETRON HCL, LOTRONEX, MOVANTIK, MOTEGRITY, RELISTOR, SYMPROIC, TRULANCE, VIBERZI 777 KB
PDF File GLP1 Receptor Agonist HHSC
Eff. Date: 7/15/2020
 ADLYXIN, BYDUREON, BYETTA, OZEMPIC, RYBELSUS, SOLIQUA, TRULICITY, VICTOZA, XULTOPHY 354 KB
PDF File Growth Hormone - HHSC
Eff. Date: 02/20/2020
 GENOTROPIN, HUMATROPE, NORDITROPIN, NORDIFLEX, NORDITROPIN FLEXPRO, NUTROPIN AQ, OMNITROPE, SAIZEN, TEV-TROPIN, SEROSTIM, ZORBTIVE 882 KB
PDF File Hepatitis C - Refill - HHSC
Eff. Date: 03/2018
 EPCLUSA, DAKLINZA, HARVONI, MAVYRET, OLYSIO, SOVALDI, TECHNIVIE, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER 77 KB
PDF File Hepatitis C Initial Request - HHSC
Eff. Date: 03/2018
 EPCLUSA, DAKLINZA, HARVONI, MAVYRET, OLYSIO, SOVALDI, TECHNIVIE, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER 102 KB
PDF File Hereditary Angioedema (HAE) - HHSC
Eff. Date: 07/15/2019
 BERINERT, CINRYZE, FIRAZYR, HAEGARDA, KALBITOR, RUCONEST, TAKHZYRO 208 KB
PDF File HP Acthar - HHSC
Eff. Date: 7/24/2020
 HP ACTHAR GEL 405 KB
PDF File Imiquimod - HHSC
Eff. Date: 3/29/2019
 ALDARA, IMIQUIMOD, ZYCLARA 219 KB
PDF File Increlex - HHSC
Eff. Date: 3/29/2019
 INCRELEX 569 KB
PDF File Inhaled Antibiotics HHSC
Eff. Date: 02/13/2020
 BETHKIS, CAYSTON, KITABIS PAK , TOBI, TOBRAMYCIN 260 KB
PDF File Ketorolac (Toradol) - HHSC
Eff. Date: 03/29/2019
 KETOROLAC 382 KB
PDF File Keveyis - HHSC
Eff. Date: 3/29/2019
 KEVEYIS 275 KB
PDF File Lidoderm Patches - HHSC
Eff. Date: 7/15/2019
 LIDOCAINE, LIDODERM, ZTLIDO 260 KB
PDF File Lovaza - HHSC
Eff. Date:: 3/29/2019
 LOVAZA, VASCEPA 267 KB
PDF File Makena (CFHP,Dell,Driscoll,ElPaso,Parklnd, S&W)
Eff. Date: 10/06/2020
 MAKENA 47 KB
PDF File Makena (CHC, CCHP, FCHP, TCHP)
Eff. Date: 10/06/2020
 MAKENA 47 KB
PDF File Monoclonal Antibody Agents for Asthma - HHSC
Eff. Date: 5/26/2020
 FASENRA, NUCALA 426 KB
PDF File Neurontin (Gabapentin) HHSC
Eff. Date: 3/29/2019
 GABAPENTIN, GRALISE, HORIZANT, NEURONTIN 673 KB
PDF File Nuplazid - HHSC
Eff. Date: 3/29/2019
 NUPLAZID 419 KB
PDF File Opioid Policy Criteria - HHSC
07/20/2020
 APAP-CAFF-DIHYDROCOD, APAP-COD, ACTIQ, APADAZ, ASCOMP/COD, BELBUCA, BELLADONNA-OPIUM, BUPRENORPHINE, BUTALB-APAP-CAFF-COD, BUTALB-CAFF-APAP-COD, BUTALBITAL COMP-COD, BUTORPHANOL, BUTRANS, CARISOPRODOL CPD-COD, COD-GUAIFEN, COD SULFATE, DEMEROL, DILAUDID, DOLOPHINE HCL, DURAGESIC, DVORAH, EMBEDA ER, ENDOCET, FENTANYL, FENTORA, FIORINAL-COD, GUAIFEN-COD , GUAIATUSSIN AC, HYDROCODON-APAP, HYDROCODONE BT-IBU, HYDROCODONE-CHLORPHEN ER, HYDROCOD-HOMATROPINE, HYDROCODONE BT-IBU, HYDROCODONE-IBU , HYDROMET, HYDROMORPHONE, HYDROMORPHONE HCL ER, HYSINGLA ER, KADIAN ER, LAZANDA NASAL SPRAY, LEVORPHANOL, LORCET, MEPERIDINE, METHADONE, METHADOSE, MORPHABOND ER, MORPHINE, MS CONTIN, NALBUPHINE, NALOCET, NINJACOF-XG, NORCO, NUCYNTA, NUCYNTA ER, OPIUM, OXYCODONE, OXYCODONE-APAP, OXYCODONE-ASA , OXYCODONE-IBU, OXYCONTIN, OXYMORPHONE HCL, OXYMORPHONE HCL ER, PENTAZOCINE-NALOXONE, PERCOCET, PROMETHAZINE-COD, ROXICODONE, SUBSYS SPRAY, TRAMADO, TYLENOL COD, ULTRACET, ULTRAM, VICODIN, VIRTUSSIN, XTAMPZA ER 1005 KB
PDF File Opthalmic Immunomodulators - HHSC
Eff. Date: 5/26/2020
 CEQUA, RESTASIS MULTIDOSE, RESTASIS EYE EMULSION, XIIDRA 267 KB
PDF File Orilissa - HHSC
Eff. Date: 3/29/2019
 ORILISSA 403 KB
PDF File Oxervate - HHSC
07/24/2020
 OXERVATE 270 KB
PDF File Oxycodone Extended Release - HHSC
Eff. Date: 3/29/2019
 OXYCONTIN, OXYCODONE HCL ER, XTAMPZA ER 2 MB
PDF File Palforzia - HHSC
07/24/2020
 PALFORZIA 294 KB
PDF File PCSK9 Inhibitors - HHSC
Eff. Date: 04/06/2020
 PRALUENT, REPATHA 543 KB
PDF File PDE5 - Inhibitors - HHSC
Eff. Date: 11/08/2019
 ADCIRCA, REVATIO, SILDENAFIL, TADALAFIL 354 KB
PDF File Phenergan (Promethazine) - HHSC
Eff. Date: 3/29/2019
 PHENADOZ, PHENERGAN, PROMETHAZINE, PROMETHAZINE-CODEINE SYRUP, PROMETHEGAN 207 KB
PDF File Phosphate Binders - HHSC
Eff. Date:01/30/2020
 AURYXIA, CALCIUM ACETATE, ELIPHOS, FOSRENOL, LANTHANUM CARB, PHOSLYRA SOL, VELPHORO 231 KB
PDF File Propylthiouracil - HHSC
Eff. Date: 3/29/2019
 PROPYLTHIOURACIL 399 KB
PDF File Ranexa - HHSC
Eff. Date: 3/29/2019
 RANEXA 374 KB
PDF File Savella - HHSC
Eff. Date: 3/29/2019
 SAVELLA 669 KB
PDF File SGLT2 Inhibitor Agents HHSC
Eff. Date: 5/01/2019
 FARXIGA, INVOKAMET, INVOKAMET XR, INVOKANA, JARDIANCE, SEGLUROMET, STEGLATRO, SYNJARDY, SYNJARDY XR, XIGDUO XR 265 KB
PDF File Sickle Cell Agents - HHSC
Eff. Date: 01/30/2020
 OXBRYTA 385 KB
PDF File Symlin - HHSC
Eff. Date: 3/29/2019
 SYMLIN, SYMLINPEN 250 KB
PDF File Synagis - HHSC
Eff. 08/11/2020
 SYNAGIS 50 MG/0.5 ML VIAL, SYNAGIS 100 MG/1 ML VIAL 774 KB
PDF File Thiazolidinediones - HHSC
Eff. Date: 3/29/2019
 ACTOPLUS MET, ACTOPLUS MET XR, ACTOS, DUETACT, AVANDAMET, AVANDARYL, AVANDIA 343 KB
PDF File Topical Acne Agents
Eff. Date: 5/10/2019
 BENZACLIN GEL, CLINDAMY/BEN GEL, ERY/BENZOYL GEL 482 KB
PDF File Topical Immunomodulators Elidel Protopic Eucrisa
Eff. Date: 8/13/2020
 ELIDEL, PROTOPIC, TACROLIMUS, EUCRISA 863 KB
PDF File Topical Retinoids
Eff. Date: 04/01/2020
 ADAPALENE, ADAPALENE-BENZYL PEROX, ALTRENO LOTION, ATRALIN, AVITA, CLINDA-TRETINOIN, DIFFERIN, EPIDUO, EPIDUO FORTE, FABIOR, TAZAROTENE, TAZORAC, TRETINOIN, TRETINOIN GEL MICRO, ZIANA GEL 365 KB
PDF File Transthyretin Agents - HHSC
Eff. Date: 04/24/2020
 TEGSEDI, VYNDAMAX, VYNDAQEL 288 KB
PDF File Tyvaso Starter Kit
Eff. Date: 07/06/2012
 TYVASO 21 KB
PDF File Urea Cycle Disorder HHSC
Eff. Date: 4/26/2019
 BUPHENYL, CARBAGLU, RAVICTI, SODIUM PHENYLBUTYRATE 169 KB
PDF File VMAT2 - HHSC
Eff. Date: 06/24/2020
 AUSTEDO, INGREZZA, XENAZINE 533 KB
PDF File Xenical
Eff. Date: 09/21/2018
 XENICAL 44 KB
PDF File Xifaxan (Rifaximin) - HHSC
Eff. Date: 3/29/2019
 XIFAXAN 288 KB
PDF File Xyrem - HHSC
Eff. Date: 3/29/2019
 XYREM 348 KB
PDF File Zelboraf - HHSC
Eff. Date: 3/29/2019
 ZELBORAF 290 KB
PDF File Zyflo
Eff. Date: 08/28/2019
 ZYFLO 483 KB
 

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